Med Form 10
Self-Administration of Medication Assessment
Client name:
Date of Birth:
Name of staff member completing assessment form:
______________________________
____/______/_______
______________________________________________________
These questions should be answered in the context of self-administration of medicine
Assessment question
Does the Client wish to self medicate?
Has the Client discussed the choice to self medicate with their family, if appropriate?
Was the Client self medicating previously?
Was the Client using a dose administration aid previously?
Is the Client orientated in time and place?
What is the Clients mini-mental exam score? See questions below
Does the Client have a history of alcohol or drug abuse?
Does the Client have any cognitive disabilities?
Does the Client have gross/fine motor skills deficit?
Is the Client able to communicate effectively?
Does the Client have any visual impairment?
Can the Client open the following:
• bottles with normal lids
• bottles with child resistant lids
• foil packets
• boxes
• dose administration aids
Assessment
YES
NO
Comments
Med Form 10
Self-Administration of Medication Assessment
Is suitable space provided for their medicines to be stored securely?
Can the Client unlock and open the drawer in which their medicines would be stored?
Can the Client read the labels on their medicines?
Does the Client understand what the medicine is for?
Does the Client know what to do if they miss a dose?
Does the Client know what to do if they take the wrong dose?
Can the Client identify the medicine?
Can the Client prepare the correct amount of medicine? (eg: expel ointment from tube to be applied to
affected area)
Can the Client administer eye/ear drops or ointment?
Can the Client administer their insulin? Has the Client been assessed as competent? (eg: by a diabetes
educator)
Can the Client apply their own patches? (and remember to remove them)
Can the Client administer inhaler devices correctly?
A No answer to any of the above questions indicates that the Client may not be competent to safely manage their medicines.
Strategies
Are there any strategies which may assist the Client self-administer?
Calendar
Medicine Cup
If Yes, list these strategies:
Yes
Med Form 10
Self-Administration of Medication Assessment
Assessed safety
Did the assessment demonstrate that the Client is capable of self-administering their medicines safely? Yes No
If Yes, complete the Client Self Medication Indemnity Form.
If No, discuss the issues with the Client. If they insist on self-medicating, ask the GP to arrange a case conference with the Client and family to discuss the
risks.
Acknowledgement that this decision was made in consultation with the Client or Client representative.
RN signature ______________________________
Ongoing review
Date
Nurse Comments
RN signature
GP comments
Initial assessment
/
/
3 monthly Review
/
/
6 monthly Review
/
/
9 monthly review
/
/
At 12 months complete new assessment.
Note: A Clients ability to self-administer medicines should be reviewed more often if their medical condition changes or they are hospitalised.
GP Signature
Med Form 10
Self-Administration of Medication Assessment
Questions related to Clients mini-mental exam score.
1. Orientation to time
‘What is the date?’
2. Registration
‘Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are... apple [pause], penny [pause], table [pause]. Now
repeat those words back to me.’
[Repeat up to 5 times, but score only the first trial.]
3. Naming
‘What is this?’ [Point to a pencil or pen.]
4. Reading
‘Please read this and do what it says.’ [Show examinee the following words on the stimulus form: Close your eyes.]